who’s paying for this, anyway??

Now that I have some more time to fight insurance, I’m starting to work on an appeal against the exclusion. I’d love to get some feedback from any readers who have an idea of how to fight insurance for orthagnastic surgery. So far, insurance has denied everything: the braces, the surgery, the hospital stay, everything. This type of surgery is an “exclusion” in my policy. Is there any hope at all for fighting an exclusion?

Without any insurance coverage, I’m looking at something like $50,000 out of pocket. If my pockets belonged to, say Bill Gates, then this wouldn’t be a problem. Â But my pockets are owned by a newlywed couple living in a one-bedroom, who have very minimal savings. Also, my husband’s school job has been cut for next year (budgets seem to be a problem everywhere, no?), so our future is looking pretty grim financially.

If insurance won’t help, I plan on trying to sell some crafty things on etsy.com while I recuperate. Not sure if I can make $50,000 worth of button decals and flower headbands, though…

3 Comments

Barbi

July 14, 2011 at 2:36 pm

LInds – email me. yes, you can get an insurance company to cover at least PART of a supposed “exclusion,” but you have to be the most annoying squeaky wheel they’ve ever heard, meaning you have to be SUPER super persistent, you have to have LOTS of research and information showing them how a) covering this will save them money versus NOT covering this in exchange for covering what COULD happen to you medically if you don’t get this surgery, and/or (b) how this is truly and verifiably (doctors notes from multiple doctors, research articles, etc, mayo clinic type stuff) medically necessary, and you have to send them these letters of appeal with ALL of this information multiple times, with multiple requests and multiple follow up phone calls. It’s a major pain the rear end, and you literally have to fill up your calendar with reminders of when to call back, who to call, who you spoke with last, who you sent the letter to, asking who received it when, etc….. but I’ve seen people get things that were totally excluded covered anywhere from 50% to 70% by doing their homework and HOUNDING their companies. You also have to NOT ever take no for an answer, and if the person you’re talking to is giving you a bunch of closed doors, as to speak with their supervisor, and then the next supervisor, and then the next if you have to, and always, ALWAYS get names and direct phone lines, for follow up calls. By the end of it, everyone working in that company should know your name and see your requests and applications for appeal coming a mile away….. make them afraid, very afraid. They don’t have the final authority, despite what they think they say, you have to show them the power and education of the consumer. What company do you have by the way? A lot of times companys are layered in their “who’s in charge of what” and the key is really making a ton of phone calls to find out WHO you really need to talk to get things done. Oh, and document EVERYTHING said and exchanged. Save everything written, and when you get off the phone write down everything that was said during the conversation including dates, times, and names. You have to act as your own lawyer, and bite them in the butt for what they say…. catch them at their own game. 😉 Anyway, let me know if you want any more suggestions.

Lindsay

November 20, 2011 at 9:54 am

Thanks, Barbi. I took a lot of your suggestions as I was calling over and over in the last few weeks. And whattya know…it worked! 🙂 Thank you for sharing your insight!

Graham

June 28, 2011 at 12:09 pm

Hi Lindsay!

I know someone from Washington state who fought with their insurance company and managed to get their jaw surgery covered. I’m not sure exactly how she did it, but I can tell you that it is indeed possible!

There’s hope!

Barbi

July 14, 2011 at 2:36 pm

LInds – email me. yes, you can get an insurance company to cover at least PART of a supposed “exclusion,” but you have to be the most annoying squeaky wheel they’ve ever heard, meaning you have to be SUPER super persistent, you have to have LOTS of research and information showing them how a) covering this will save them money versus NOT covering this in exchange for covering what COULD happen to you medically if you don’t get this surgery, and/or (b) how this is truly and verifiably (doctors notes from multiple doctors, research articles, etc, mayo clinic type stuff) medically necessary, and you have to send them these letters of appeal with ALL of this information multiple times, with multiple requests and multiple follow up phone calls. It’s a major pain the rear end, and you literally have to fill up your calendar with reminders of when to call back, who to call, who you spoke with last, who you sent the letter to, asking who received it when, etc….. but I’ve seen people get things that were totally excluded covered anywhere from 50% to 70% by doing their homework and HOUNDING their companies. You also have to NOT ever take no for an answer, and if the person you’re talking to is giving you a bunch of closed doors, as to speak with their supervisor, and then the next supervisor, and then the next if you have to, and always, ALWAYS get names and direct phone lines, for follow up calls. By the end of it, everyone working in that company should know your name and see your requests and applications for appeal coming a mile away….. make them afraid, very afraid. They don’t have the final authority, despite what they think they say, you have to show them the power and education of the consumer. What company do you have by the way? A lot of times companys are layered in their “who’s in charge of what” and the key is really making a ton of phone calls to find out WHO you really need to talk to get things done. Oh, and document EVERYTHING said and exchanged. Save everything written, and when you get off the phone write down everything that was said during the conversation including dates, times, and names. You have to act as your own lawyer, and bite them in the butt for what they say…. catch them at their own game. 😉 Anyway, let me know if you want any more suggestions.
- Lindsay
  
  November 20, 2011 at 9:54 am
  
  Thanks, Barbi. I took a lot of your suggestions as I was calling over and over in the last few weeks. And whattya know…it worked! 🙂 Thank you for sharing your insight!
Graham

June 28, 2011 at 12:09 pm

Hi Lindsay!

I know someone from Washington state who fought with their insurance company and managed to get their jaw surgery covered. I’m not sure exactly how she did it, but I can tell you that it is indeed possible!

There’s hope!